Health inspection·January 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of verbal abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of four residents reviewed (Resident 1). This failure had potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. Findings: On December 6, 2023, at 10:53 a.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report of an allegation of abuse involving a Certified Nurse Assistant (CNA), a License Vocational Nurse (LVN) and a resident. On December 13, 2023, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included blunt head trauma (head injury resulting from contact between the head and another object). A review of Resident 1's History and Physical, dated November 26, 2023, indicated Resident 1 is alert and oriented to name, date of birth and location. A review of Resident 1's Nursing Narrative Note, dated December 6, 2023, at 4:35 a.m., indicated, .Patient requesting a new gown .Writer brought new gown in instead of sending CNA in an effort to diffuse patient agitation .Patient still angry and stated that woman needs to check her attitude .If I were home I ' d get in the shower .this is elder abuse . A review of Resident 1's Nursing Narrative Note, dated December 6, 2023, at 6:03 a.m., indicated, .Writer heard patient struggling with his front wheel walker (a device use to help maintaitain balance while walking) .Entered room to assist .Patient stated get my bag .Writer ask patient to repeat himself .Patient shouted don ' t chastise (criticize) me .This is elder abuse . A review of Resident 1's Nursing Note Form, dated December 6, 2023, at 8:30 a.m., indicated, .Met with patient regarding his allegation of verbal abuse he experience from his interaction with night shift .He reiterated that he felt what was said to him amounted to elder abuse . Page 1 of 2 555417 555417 01/03/2024 Desert Regional Medical Center D/P Snf 1150 North Indian Canyon Drive Palm Springs, CA 92262

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On December 13, 2023, at 9:58 a.m., during an interview with the Director of Nursing (DON), the DON stated he was notified of the abuse allegation incident on December 6, 2023, at 8:30 a.m. The DON stated he reported the incident to CDPH on December 6, 2023, at 10:00 a.m. On December 13, 2023, at 2:20 p.m., during an interview with LVN 1, she stated, on December 6, 2023, around 4-5 a.m., Resident 1 told her CNA 1 and you need to check your attitude, this is elder abuse. LVN 1 further stated on December 6, 2023, at 6:00 a.m., Resident 1 stated dont touch me, this is elder abuse. LVN 1 stated, any abuse or allegation of abuse needs to be reported immediately within 2 hours after the allegation was made. LVN 1 stated, the incident was reported to CDPH on December 6, 2023 at a later time around 10:00 a.m. (6 hours after the allegation was made). LVN 1 further stated, she should have reported the abuse allegation incident to CDPH within 2 hours. On December 28, 2023, at 1:06 p.m., during an interview with the DON, the DON stated, any abuse allegation must be reported immediately within 2 hours to CDPH to keep the resident safe. The DON further stated, the facility abuse reporting guidelines is based on the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (primary survey and certification rules and guidance). The DON stated, LVN 1 should have reported the abuse allegation immediately within 2 hours after Resident 1 made the allegation. The DON further stated, the abuse allegation was reported to CDPH five to six hours after Resident 1 made the allegation. A review of the facility policy and procedure titled, DES SNF-ABUSE, dated December 17, 2020, indicated, .Investigate and report any such allegation of abuse .pursuant to all federal, state, and local laws . 555417 Page 2 of 2